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The Fourteen Challenges That Every Nurse Manager Must Be Prepared to Address

The Nurse Manager plays an essential role in healthcare. She sets the tone of any Healthcare System. The Manager is the backbone of the organization. The quality of patient care, as well as staff recruitment and retention success, rests with this key role. Over time it will be the strength of the Nurse Manager group that determines the success or failure of nursing leadership, the COO, and even the CEO.

And yet it is rare that Nurse Managers are given the opportunity to acquire the operational, financial, and management skills essential to their success – and the success of their organization.

This manual and Program have been created to provide Nurse Managers with the tools and skills required for organizational and career success.

Before jumping into specific tools and competencies, it is important to explore the many challenges that the Nurse Manager faces in her role. In fact, there may be no more challenging career – in any industry – than the Nurse Manager.

Following are fourteen challenges that Nurse Managers must be prepared to address:

Challenge #1: The broader context of the healthcare industry and its ongoing crisis

The healthcare industry is in crisis, and the Nurse Manager has to be proactive in dealing with this crisis every shift, every day. Among the challenges in healthcare, especially in the inpatient arena:

• A budget crisis in Medicare and Medicaid which will continue to put pressure on hospitals   to cut costs.

• Increases in the number of uninsured patients, causing severe financial strain.

• Overflowing emergency rooms without adequate staff to care for patients awaiting   transfer to over-crowded in-patient beds.

• The changing patient demographic place new and increasingly costly demands on the   healthcare system. Dangerous lifestyle practices, drug and alcohol abuse, obesity,., ever   advancing technology, keeping critically ill patients alive far longer than would have been   the case even ten years ago, HIVAIDS, etc., pressure a spent and weary societal and   economic system.

• In an effort to mollify reductions in reimbursement, physicians join entrepreneurs in   launching specialized, highly profitable start-ups (i.e. outpatient surgical centers, imaging   centers, and free standing treatment facilities) that drain patients and profits away from   the hospital, and threaten the non-profit mission of many hospitals.

• The expectation that hospitals will provide a consistent standard of care, despite being   reimbursed according to many different payment models and incentives. For instance,   there is an inherent conflict between a per diem payment program and a cost-per-case   payment approach; in purely economic terms the latter favors a rapid discharge while the   former may not.

• A highly litigious society whose members are increasingly skeptical and suspicious of the   care they receive.

For the Nurse Manager, these trends mean that she must continue to provide the highest quality of patient care despite severe budget pressure to keep costs in line. Unfortunately, as administrators in many health systems bemoan, “There is nothing left to cut.”

While the Nurse Manager can’t be expected to achieve miracles, she will be expected – now more than ever -- to run an incredibly efficient, productive, and high-quality unit. And, given the financial impact of staffing decisions, it is essential that the Nurse Manager have the ability to clearly articulate an acceptable rationale for staffing and spending in a particular manner

Challenge #2: Changes in nursing and negative perceptions about the profession

The nursing profession has faced enormous strains over the past decade, resulting in the current shortage of nurses we have today. While this labor challenge will be considered separately, a deeper challenge has to do with the overall perceptions of the Nursing profession, especially from within.

Nursing as a profession is in crisis, a crisis that Nurse Managers must attempt to mitigate every day. The long standing perception that Nursing is a rewarding and privileged profession has been diluted in the last decade, for the following reasons:

• Nursing has always been a physically demanding profession. Today the physical demand   is as great as ever with the added challenge of highly technical and increasingly complex   treatment modalities. The nurse is an analyst, a communicator, a facilitator, a problem   solver, a decision maker, and above all a clinical expert. Nursing requires a broad   theoretical base and a new and ever changing clinical skill set, along with the ability to   integrate theory with clinical practice. Without the necessary educational preparation and   on-going in-service training the nurse will feel overwhelmed, stressed, and unsupported.   And to the Nurse Manager falls the task of assuring that her staff doesn’t lag behind and   that high quality patient care is sustained regardless of newly imposed expectations.

• Integrating inexperienced nurses onto the unit with the nurturing and encouragement they   need is a primary charge to the Nurse Manager. Yet the pressure of daily life on a nursing   unit often precludes time for true mentoring and the TLC that is integral to fostering trust   and commitment in orienting staff. A failure in this realm leads to diminished morale and   high turnover among the nursing staff.

• Nurses will feel underappreciated, even abused by administration, physicians, patients, and   their chosen profession, when the organizational culture makes demands but forgets to   acknowledge and reward nurses’ contributions at all levels in the organization.

• Nursing leadership should work hard at promoting nursing as the rewarding, privileged   profession that it is. Unfortunately among ourselves and sometimes in public we paint a   picture of the profession that focuses on workload and fails to talk about the life and death   issues that nurses successfully confront each day. We forget to talk about our amazing   satisfaction in knowing that this is not about a production line of “widgets”, not a dress   rehearsal, but the real thing.

As a result, Nurse Managers have a challenging time creating a positive, productive, high-morale climate on their units. Nursing staff comes to its work already feeling underappreciated and negative. The Nurse Managers have to cope with these attitudes and create a positive tone.

Challenge #3: Silos and communication issues within the hospital or health system

Hospitals are enormously complex entities. Communication is sometimes less effective than it could be at the top of the organization, and this problem trickles down to the nursing units. Once again, the Nurse Manager has to deal with these issues.

For instance, the Chief Operating Officer (COO), VP of Nursing Care, and Chief Financial Officer (CFO)may have conflicting agendas, even as everyone works in good faith to achieve institutional objectives. The CFO necessarily focuses on the numbers and on the bottom line, and may be less sensitive to more intangible issues. The VP of Nursing Care has to balance the financial numbers with quality, service, accreditation, and labor pressures. The COO can find him or herself to be in the uncomfortable position of balancing both – while also responding to physicians and other constituents. Other leaders in the organization, such as the Chief Medical Officer and Chief Information Officer, also have priorities that impact on and require the cooperation of the nursing unit staff.

As a result, the Nurse Manager can feel “caught in the middle,” being pulled and tugged from multiple directions.

At the same time, silos up and down the organization may hinder smooth communication across it. The Nurse Managers may experience difficulty getting good information or response from people outside their chain of command.

It takes a politically-sensitive manager who can build strong alliances and relationships to manage this challenge.

Challenge #4: The variability of resource requirements on the unit

While obvious to many reading this book, it is still important to reiterate explicitly: Running a nursing unit is nothing like running a manufacturing assembly line.

In the typical manufacturing assembly line, managers have excellent visibility about upcoming production requirements. Weeks in advance they know how many units need to be produced. Product specifications don’t routinely change; there is minimal variability of resources required to produce a single unit. Most importantly, a product is an inanimate object.

Patient care presents a radically different picture. And it is a radically different picture today than was presented on nursing units in the past. The complex world of manufacturing looks simple by comparison. There is little long-term predictability about patient acuity or demand for in-patient beds. Shift-by-shift resource requirements are often impossible to anticipate accurately, yet require very specific and timely staffing adjustments. The hospital census may have a one hundred patient census variation from day to day. On one shift a twenty-six bed nursing unit could have thirteen empty beds, while an influx of patients eight hours later may fill the unit to an overflow status. The introduction of thirteen additional patients will require four or five additional nurses per shift. Similarly patient acuity will vary day to day requiring more, or less, intensive resources. The ability of the manager to make an educated calculation and plan skillfully for these fluctuations will mean significant expense avoidance by the end of the month. Over staffing every day for example by just one patient at eight nursing hours per patient day (8 NHPPD at $ 30/hr) is an over spend of approximately $7,200 a month. If the same situation occurs each month the manager will have “over spent” her budget by $86,400, annualized. Were ten units to do the same thing it would have an unfavorable impact on the bottom line of close to a million dollars.

As important, the Nurse Manager also has the task of supporting staff, explaining the logic of her staffing strategies, and convincing staff members of the importance of being flexible when conditions on the unit change. This may mean urging staff to take additional shifts, perhaps work overtime, or reduce hours because of low census. Herein is a measure of the manager’s alliance with staff and the trust and loyalty she has engendered over time through fair and open relationships.

It is no surprise the management guru Peter Drucker argued that running a hospital is the most challenging management task one can have. The same observation applies to inpatient units and the Nurse Manager’s responsibility.

Challenge #5: Making the transition from staff to management

The new Nurse Manager, most often promoted from within, has to make a complicated transition. One day she is a peer with her colleagues on the nursing unit, seeing them socially, sharing unit stories. The next day she is a Nurse Manager with entirely new responsibilities and accountability for outcomes on the nursing unit. Major adjustments are requisite and the learning curve is steep. These adjustments include:

• Developing alliances at new levels up, down and across the organization.

• Recognizing, understanding, and dealing with envious staff who may have coveted the   management position.

• Being scrupulously fair and equitable, regardless of previous relationships, in scheduling   time, allocating holidays and overtime and showing consideration and flexibility in meeting   individual time requests for outside commitments.

• Demonstrating a commitment to twenty-four hour accountability and availability by   regularly visiting all shifts, giving employees on each shift annual performance appraisals   on time, and working closely with off-shift supervisors to assure that patient care   standards are being maintained around the clock.

• Dealing with unions (if applicable) as a manager, not a union member.

• Doing what it takes to get results, regardless of the start or end of a shift or the assigned   tasks.

• Gaining a new perspective that extends beyond the nursing unit to include the overall plan   for the hospital as a larger system.

• Acting like an “owner” of the organization, and understanding that it doesn’t take much   for a hospital to go from barely above breakeven to in the red.

• Getting on the “same side of the table” with senior leaders in the hospital, and being a   positive, professional voice for the organization.

Challenge #6: 100% responsibility without 100% authority

Moving beyond influence with her immediate reports, the manager must be creative and resourceful in how she acquires clinical and support services from departments over which she has no formal authority. The success of a Nurse Manager will be measured in large part by her alliances with other departments and her ability to make things happen in order to move patients seamlessly through the system. The rapidity with which diagnostic tests are completed, discharges are handled, rooms cleaned and prepared for the next patient, and equipment delivered is a direct reflection on the skill and ability of the manager. Managing unpredictable variability in all of the areas mentioned is clearly the Nurse Manager’s responsibility and one of her greatest challenges.

The new Nurse Manager may be uncomfortable or frustrated when she realizes that she has 100% responsibility for everything that happens on her unit, without 100% authority. That’s because she has to rely partially on other departments (e.g. housekeeping, food services, pharmacy, etc.) for her success. The successful seasoned manager has developed interpersonal skills, interdepartmental relationships, and the skill to apply effective influence, even lacking formal authority.

In any hospital where I’ve worked, there have been variations in how well different Nurse Managers forge these alliances and relationships. This can be seen in efficiency of operations on the unit, relationships with physicians, patient and staff satisfaction survey scores, and a sense of mutual respect and collegiality among disciplines and departments. The successful manager eliminates the “silo” mentality on her nursing unit. She sets high standards for herself and those with whom she works and she consistently expects and maintains those standards, regardless of where the formal authority rests.

Challenge #7: Labor

For Nurse Managers in unionized environments, the challenges grow even larger. There is a serious risk in healthcare that leadership at hospitals will lose its management prerogative, the ability to determine appropriate staffing resources and manage unique units according to the changing needs of the patients. Evidence of this is plentiful in states such as Massachusetts and California where the nursing unions are promoting legislated mandatory staffing levels and attempting to usurp management rights.

Effective Nurse Managers must be savvy enough to know how to deal effectively with unions, and avoid legal issues. Working in a unionized setting is not intuitive. Well run organizations are prepared to educate managers to avoid pitfalls. Once again alliance building is key, particularly between managers and union representatives, in managing day to day situations. If the environment becomes hostile because trust is lost, it is difficult to right the situation. The Nurse Managers are the critical players. They must act with strict regard for the contract agreement, avoid decisions that might appear arbitrary or capricious, be consistently fair and equitable, document all issues, and handle any grievances appropriately. A close relationship between the Nursing Department and the Human Resources department is indispensable in managing union relations.

No matter how much training and support the hospital provides, some Nurse Managers have staff members who go to the union with labor relations complaints day after day. The nurse executive, the union attorney and the hospital attorney may have to be involved. Although enormously time consuming and disruptive, to some extent this kind of turmoil is predictable and unavoidable…a phenomenon of labor relations activity. However there are managers who are able to mitigate events before things escalate. They are wiser than others in recognizing and avoiding what will provoke staff; and they are meticulously fair in setting expectations, assigning hours, counseling staff, and taking disciplinary action. Strategies that these managers employ should be analyzed, understood, and incorporated into department wide practices.

A Nurse Manager may have to work with a union representative who is inexperienced, has a hidden agenda, or is trying to prove that she is representing her members well by challenging management. In this case, the manager needs to collaborate with nursing leadership and human resources to devise a strategy that addresses the issues being raised, doesn’t conflict with the contract, but maintains control in the hands of management.

One of the most sensitive issues that a manager will face is a staff complaint of harassment. The complaint may be that someone used inappropriate language or displayed a threatening demeanor when tensions were high. Or a nurse may complain about unwanted attention from a physician or other member of the hospital team. Typically the nurse will go to the union representative if the manager is ineffective in assuring the unwarranted and uninvited behavior will stop. It is essential that the manager sort out the facts and take action if appropriate. Harassment in the work place can not be tolerated. However damaging accusations must be investigated carefully. The Nurse Manager should work closely with the Human Resources Department and the hospital attorney to analyze the situation and assure that proper procedures are followed.

Challenge #8: Staff management, recruitment and retention

Nursing remains primarily a women’s profession with less than ten percent male nurses. Unlike twenty or thirty years ago, women today have many career options and, as they make choices in law, business, industry, medicine, or whatever, the pool of nurses diminishes. In addition the nursing workforce is aging. Thirty years ago the average age of the nurse was twenty-four. Today the average age of the nurse is forty-eight. Looking ahead just a very few years we will be faced with the retirement of numbers of nurses now staffing our hospitals. And the demand for talented, committed, and well educated nurses has never been greater than it is today. Hospitals are aggressively competing for registered nurses, particularly those with specialty high tech experience. Those hospitals that are well endowed and can raise salaries are doing so. Entrepreneurs are turning the nurse into a for-profit commodity by becoming ‘middle men’ marketing travel and local agency nurses to hospitals, greatly increasing personnel cost. So staffing issues are a constant worry for the Nurse Manager.

As in countless situations the manager’s ability to build an alliance with staff, convince nurses that she will always treat them fairly with dignity and respect will have a true impact on her ability to recruit and, as importantly, retain qualified nursing staff. So once again we see the importance of well honed interpersonal relationship skills. Retention of capable nurses is as critical as recruitment. Each new graduate nurse that is hired and oriented costs the institution nine or ten thousand dollars in orientation and coverage costs before she is ready to assume responsibility for a patient assignment. If the new graduate nurse is being recruited to a critical care area, the orientation is longer and the cost greater. It is a simple mathematical exercise, but the answer is startling.

The problem of needing more nurses than are available is a system wide problem. The solution lies in collaboration between academia, the practice setting and the third party payers. It will become increasingly necessary to access a new pool of nursing prospects. It may be that we will need to provide remedial education programs to adult learners who have been out of school for a long time but are looking for a career change in mid-life. Individuals who have English as a second language might be another source of nurses, but only if appropriate programs are put in place so that they can compete in the academic setting and in the market. The opportunity to enter a profession might be very attractive to minority groups and economically disadvantaged women and men if the right programs are in place to provide support, prerequisite training and hope of true success.

Meanwhile, per diem resources come and go without true commitment or even time for a reasonable orientation to the unit. And despite all this the manager must assure that staff coverage is adequate today. All of this weighs heavily on the Nurse Manager’s shoulders.

The well-prepared manager learns to cope with this crucial challenge. She understands what is needed, remains resilient, and does what the patient, her staff, and the hospital need. She identifies, recruits, and retains talent for her organization, while screening out less qualified candidates. And she serves as a positive mentor, role model, and leader of her staff despite the intricacies of unanswered questions plaguing the healthcare industry and the nursing profession today.

Challenge #9: Many stakeholders

As noted earlier, the Nurse Manager has to forge alliances with a large number of stakeholders: her own managers, her staff, unions, physicians, and managers of other departments. Some of these stakeholders are particularly difficult, demanding, and even abusive.

The successful Nurse Manager builds advocates up, down, and across the organization – with or without formal authority. She learns how to influence people in ways that balance results and relationships, without sidestepping conflict or being inappropriately assertive.

Challenge #10: Quality

The reason we go into nursing is to provide quality patient care. This mandate becomes harder all the time, especially given the financial and staffing issues that healthcare organizations are facing.

Nevertheless, the Nurse Managers is the person responsible for maintaining quality on the unit. She must define what quality means on her unit, set standards for quality, develop consistent processes, eliminate errors, measure results, and constantly improve performance.

In the context of this book, quality includes the traditional measures (e.g. infection rates, medication errors, having a quality program and being able to articulate it) as well as some operational issues that are not typically classified as quality but actually are. These include basic responses to events on units such as reporting results of tests, communicating with physicians who call looking for information or asking for assistance, turning rooms over, completing charts, etc.

Challenge #11: Budget and financial management

In an inpatient unit, with lives at stake, nothing is purely financial. For this and other reasons, the Nurse Manager may find it difficult to make balancing the budget a priority:

• Real time information may not be forthcoming from the Finance Department. If this is the   case, the prudent manager will develop customized monitoring tools and reports and use   them to adjust unit operations to conform to budget expectations and to eliminate   surprises at months end. This can be problematic if the manager’s reports don’t exactly   match those produced later by the Finance Department, but real-time information is the   only way to successfully meet budget targets. Without information it is impossible to   explain decisions made, analyze outcomes, and articulate a rationale.

• The Nurse Manager has to work with averages, perhaps going over budget on a   particularly high-acuity day, and then staying under budget on more reasonable days. It   can be difficult to see the forest for the trees in this situation. But the manager who has   facts and figures available and confidence in her own judgment can make this work.

• Many Nurse Managers have never received training in building and meeting a budget, or in   analyzing financial reports about their units.

• The variability of patient care requirements, as discussed previously, can easily skew the   budget process.

• The Nurse Manager’s budget may depend on factors outside her control, such as   assumptions about average patient acuity or overall demand for beds.

• Meeting a budget requires diligence and discipline during and between shifts. Small   oversights in use of per diem, overtime, and completion of paperwork can quickly add up   to large variances.

Also, some Nurse Managers do not take financial management as seriously as they should. Many work under the very mistaken assumption that hospitals have some secret pool of emergency money available if budgets are not met. Unfortunately, this assumption is dangerously incorrect. There is no secret pool of funds, and many hospitals teeter precariously on the verge of shutting down. In recent years, many hospitals have even depleted their endowments in order to stay viable.

At the end of the day, finances are measurable and specific – and leave no doubt about whether a Nurse Manager is performing or not. To be successful, Nurse Managers must become adept at understanding and meeting a budget.

Challenge #12: Time management

There are more demands on the Nurse Manager’s time than there are hours to fill the day. If she is not careful, the Nurse Manager may become mired in administrative meetings and be away from her unit too much of the day. Staff will feel neglected, morale will suffer, and outcomes may deteriorate. Physicians also expect to spend quality time with Nurse Managers, reviewing patient progress and explaining changes in treatment modalities.

It is up to the Nurse Manager to set priorities for her time and find creative ways to handle both the demands of her unit and the organization at large. There is also an opportunity for the Nurse Manager group to work together sharing some of the meeting burden and keeping colleagues, not in attendance, informed and up to date.

Challenge #13: The inner game and resilience

In light of all of the above, it makes perfect sense that the Nurse Manager’s role sometimes seems impossible, overwhelming, even frightening.

Sometimes the challenges seem insurmountable.

Still successful Nurse Managers are able to bounce back in the face of adversity, take responsibility for their units, and do what it takes to persevere. They see that the bigger picture is all about caring for the patient, and they make what can accurately be called a heroic effort to keep moving forward.

Challenge #14: Self-development

The final challenge for the Nurse Manager often gets left behind given all of the immediate fires that need extinguishing on the unit. This is the challenge of ongoing self-development, career development, and improvement. Personal and professional development is both a responsibility and a right.

It is too easy for the Nurse Manager to get lost in daily activities and neglect her longer term aspirations and career path. Nurse Managers should be constantly answering these questions:

• What are the best ways to “pay my dues” and learn at the right pace without being   overwhelmed by an unmanageable role?

• Should I get a Masters Degree in order to be prepared?

• How can I be sure that my manager gives me an honest open performance appraisal?   How can I best open myself to feedback, coaching, and advice?

• What kinds of continuing education will be serve me?

• What is the appropriate time line for me to learn what I need to know and advance?

• Should I work in a community or academic medical center setting?

• Which leaders can I seek out as mentors?

• Who can I mentor?

• What is my 3-year and 5-year development plan?

Just as Nurse Managers must take 100% responsibility for their units, so must they take 100% responsibility for their own career.

Addressing These Challenges

As already noted, these challenges – taken alone and especially as a whole – may seem daunting. Not every Nurse Manager will be able to handle them, and some Nurse Managers may find that the role is not right for them.

This Manual now shifts to addressing the challenges that the Nurse Manager must face in order to be successful. It does this by focusing on three areas:

Intellectual Content. Intellectual content encompasses ways to analyze and think about performance on your unit to control it and get results. Topics include:

• Understanding the operations and systems in a hospital setting – from a leadership   perspective and from the patient’s point of view.
• Developing and meeting a budget.
• Implementing shift-by-shift planning tools.
• Implementing quality and performance improvement tools, including metrics.
• Developing financial analysis and problem solving skills to make sound decisions.

Interpersonal Process. Interpersonal process focuses on relationships, communication, and situational management. It includes:

• Setting standards and the tone for your unit.
• Building alliances with staff and key stakeholders outside the unit.
• Balancing results and relationships.
• Influencing effectively without authority.
• Communicating clearly, both in writing and orally.
• Political awareness and sensitivity.
• Managing staff the most effective way given the situation.
• Working with physicians.
• Managing up the organization.
• Managing across the organization.
• Building an effective staff/team.
• Dealing with labor and union issues.
• Managing your time effectively.

Context. Context refers to the environment you create as well as your internal state as you manage the unit. It includes:

• Your commitment.
• Your “coachability”.
• Your standards.
• Your resiliency and calm under pressure.
• Your proactivity; initiative and risk taking
• Your flexibility.
• Your loyalty.
• Your ability to balance short- and long-term perspectives.
• Your ability to eliminate blind spots, take responsibility and be decisive.
• Your ability to focus on results vs. status or harmony.
• Your ability to be a leader who is no longer a part of staff.
• Your self-knowledge and ongoing development.

Each of these areas is important and they work together. Content provides solid concepts for managing daily operations and leading staff. Interpersonal process is how you get things done effectively with other people. Context is your way of being within the interrelated conditions on your unit and the professionalism that enables you to be resilient and persevere.

Without mastering any one of these areas, you will not be as successful. For instance, if you have a solid grasp of content but lack interpersonal process skills, you won’t form the alliances with people required to get things done. If you lack the contextual skills, you won’t have the positive attitude needed to be effective. And if you have interpersonal skills and contextual skills but lack content, you will be well-liked but unable to make effective analyses and decisions to improve your unit.

If you can master these three areas, you will succeed in this most challenging yet crucial role and have a satisfying career in Nursing Management.